A patient is diagnosed with diabetic polyneuropathy.
Using ICD-10-CM coding guidelines, what ICD-10-CM coding is reported?
A patient who has colon adenocarcinoma undergoes an open partial colectomy. The surgeon removes the proximal colon and terminal ileum and reconnects the cut ends of the distal ileum and
remaining colon.
What procedure and diagnosis codes are reported?
According to the ICD-10-CM Guidelines, what code is reported as an additional code when the blood pressure of a patient with hypertension remains above goal in spite of the use of antihypertensive medications?
A diagnostic mammogram is performed on the left and right breasts. Computer-aided detection is also used to further analyze the image for possible lesions.
What CPT® coding is reported for this radiology service?
View MR 005398
MR 005398
Operative Report
Preoperative Diagnosis: Nonfunctioning right kidney with ureteral stricture.
Postoperative Diagnosis: Nonfunctioning right kidney with ureteral stricture.
Procedure: Right nephrectomy with partial ureterectomy.
Findings and Procedure: Under satisfactory general anesthesia, the patient was placed in the right flank position. Right flank and abdomen were prepared and draped out of the sterile field. Skin incision was made between the 11th and 12th ribs laterally. The incision was carried down through the underlying subcutaneous tissues, muscles, and fascia. The right retroperitoneal space was entered. Using blunt and sharp dissection, the right kidney was freed circumferentially. The right artery, vein, and ureter were identified. The ureter was dissected downward where it is completely obstructed in its distal extent. The ureter was clipped and divided distally. The right renal artery was then isolated and divided between 0 silk suture ligatures. The right renal vein was also ligated with suture ligatures and 0 silk ties. The right kidney and ureter were then submitted for pathologic evaluation. The operative field was inspected, and there was no residual bleeding noted, and then it was carefully irrigated with sterile water. Wound closure was then undertaken using 0 Vicryl for the fascial layers, 0 Vicryl for the muscular layers, 2-0 chromic for subcutaneous tissue, and clips for the skin. A Penrose drain was brought out through the dependent aspect of the incision. The patient lost minimal blood and tolerated the procedure well.
What CPT® coding is reported for this case?
The pulmonologist performs a bronchoscopy with fluoroscopic guidance. The scope is introduced into the right nostril and advanced to the vocal cords and into the trachea. The scope is advanced to the right upper lobe and a lung nodule is noted. An endobronchial biopsy is performed.
What CPT® code is reported for the procedure?
A 55-year-old patient with suspected liver cancer was seen by the physician to obtain a biopsy. The special biopsy needle was placed using ultrasonic guidance. The physician obtained a small tissue sample from the liver, which was then sent to pathology.
What CPT® codes are reported?
A patient has chronic cholesteatoma in the right middle ear. The otolaryngologist performed a tympanoplasty with a radical mastoidectomy, removing the middle ear cholesteatoma. Grafting
technique was used to repair the eardrum with ossicular chain reconstruction.
What CPT® code is reported for this surgery?
A 67-year-old male presents with DJD and spondylolisthesis at L4-L5 The patient is placed prone on the operating table and, after induction of general anesthesia, the lower back is sterilely prepped and draped. One incision was made over L1-L5. This was confirmed with a probe under fluoroscopy. Laminectomies are done at vertebral segments L4 and L5 with facetectomies to relieve pressure to the nerve roots. Allograft was packed in the gutters from L1-L5 for a posterior arthrodesis. Pedicle screws were placed at L2, L3, and L4. The construct was copiously irrigated and muscle; fascia and skin were closed in layers.
Select the procedure codes for this scenario.
A 62-year-old with ventricular fibrillation comes to the outpatient surgery department for the replacement of a pacing cardioverter-defibrillator. The procedure is performed under MAC
anesthesia. The Certified Registered Nurse Anesthetist (CRNA), is working independently without medical direction.
What CPT® and ICD-10-CM codes are reported for the CRNA?
